New onset of uveitis during infliximab treatment: A case report.

INTRODUCTION: Anti-tumor necrosis factor α (anti-TNF α) agents are an effective treatment for a variety of inflammatory and autoimmune diseases. In ophthalmology anti-TNF α began to emerge as a possible therapy for non-infectious uveitis, paradoxically their administration may result in the onset or recurrence of inflammatory eye disease such as uveitis. We reported a case of new onset of bilateral anterior and intermediate uveitis in a patient with rheumatoid arthritis (RA) while being treated with infliximab and we performed a review of literature. OBSERVATION: A 25-year-old female with RA under infliximab, presented with bilateral blurred vision. Anterior segment examination demonstrated retrodescmetic fine precipates, 1+ cells in the anterior chamber on both eyes. The fundus examination was difficult because of the vitritis. Fluorescein angiography demonstrated mild optic disc edema, and bilateral diffuse peripheral fern leaf cappilaritis. Optical coherence tomography showed severe cystoid macular edema bilaterally. The diagnosis of bilateral anterior and intermediate uveitis caused by infliximab was retained after exclusion of infectious and autoimmune aetiologies. She was treated with corticosteroid with good visual outcome. CONCLUSION: In our case, new onset of uveitis may be considered as paradoxical effect of anti-TNF α therapy. Rheumatologists and ophthalmologists should be aware of this effect. Careful monitoring of patients under infliximab is necessary for appropriate diagnosis and early treatment.

Short-Term Total Tamponade with Perfluorocarbon Liquid and Silicone Oil in Complex Rhegmatogenous Retinal Detachment with Severe Proliferative Vitreoretinopathy.

Background: To evaluate retinal reattachment, visual functional results, and complications rates after total tamponade (TT) with perfluorocarbon liquid (PFCL) and silicone oil (SO) for 2 days followed by PFCL-SO exchange in complex retinal detachment (RD). Methods: Retrospective study including 52 consecutive eyes with complex RD and advanced proliferative vitreoretinopathy, who underwent vitrectomy with TT. Patients underwent first surgery by 25-Gauge vitrectomy and partial PFCL-SO exchange (approximately 60% PFCL 40% SO fill) followed by second surgery with extraction of the PFCL and complete SO fill. Results: After a mean follow-up period of 25.15 ± 6.6 months, the retina remained reattached in 48/52 eyes (92.3%) including 28 eyes (58.3%) without SO and 20 eyes (41.7%) with prolonged SO tamponade. Visual acuity improved in 45 eyes (86.6%) (P<0.001), remained stable in 4 eyes (7.7%) and decreased in 3 eyes (5.7%). Complications consisted in mild anterior chamber inflammation in 10 eyes, ocular hypertension in 12 eyes, and cataract in 10 eyes. Conclusion: Two-day TT with PFCL and SO may be considered in complex RD with advanced proliferative vitreoretinopathy especially in monocular patients. Further studies with longer follow-up period and retinal electrophysiologic assessment may be needed.

Uncommon bilateral optic neuropathy in Wernicke's encephalopathy complicating gravidarum hyperemesis.

Wernicke encephalopathy (WE) is a rare neurological disorder that results from vitamin B1 (Thiamin) deficiency, classically characterized by the triad of ophtalmoplagia, altered consciousness, and ataxia. WE is often associated with alcoholism, malnutrition, or gastrointestinal diseases with malabsorption. The association of «gravidarum hyperemesis¼ and WE seems to be underestimated. We report a 24-year-old pregnant woman with hyperemesis gravidarum, who presented with decreased visual acuity of both eyes. Fundus examination showed a bilateral stage 2 papillary edema. brain magnetic resonance imaging (MRI) showed bilateral and symmetrical hyper intense lesions on T2-weighted and FLAIR sequences in periaqueductal gray matter, thalamus, and mammillary bodies, which confirmed WE complicated by bilateral optic neuropathy. Her symptoms resolved after thiamine treatment. This case raises of the possibility of optic neuropathy in WE, which is a diagnostic emergency requiring early treatment to prevent complications.

Visual disorders and fitness for professional driving.

BACKGROUND: The professional driver's post is a security post that requires a careful assessment of the visual functions influencing the medical fitness decision. Professional driving benefits from a codified regulation regarding vision disorders. However, it suffers from several shortfalls making the task of the occupational doctor sometimes difficult. AIM: To identify the ophthalmological pathologies that have influenced the fitness decision for professional driving and develop a fitness approach for professional driving according to the different ophthalmological pathologies encountered. METHODS: We conducted a retrospective, descriptive study from the files of professional drivers with visual impairment who consulted the department of occupational health at Charles-Nicolle Hospital of Tunis for medical fitness decision, during the period from January 1, 2008 to December 31, 2016. RESULTS: Sixty drivers were included in the study. The population gender was exclusively male. Mean age was 48 ± 8.43 years. A pathological medical history was found in 70% of patients, mainly represented by: Diabetes (37%) and high blood pressure (28%). Truck drivers were the most represented (45%) and the average of professional experience was 14 years with extremes ranging from zero to 33 years. In 75% of cases, patients had one or more functional complaints. The decrease in visual acuity was the common reason for consultation (55% of cases). Diabetic retinopathy was the ophthalmological diagnosis most commonly found in our study (18% of cases). Diabetic retinopathy was the leading cause of definitive disability in our study (32% of cases). Other ophthalmologic causes of definitive disability were: Glaucoma, amblyopia, homonymous haemianopia, age-related macular degeneration, blindness or functional loss of one eye, diplopia, retinal detachment and uveitis complicating Behcet's disease. CONCLUSION: At the end of this study, we showed regulatory deficiencies for which we suggested recommendations that could help the occupational physician to take medical fitness decisions.

Valsalva retinopathy occurring after general anesthesia.

PURPOSE: To report a case of patient who presented with valsalva retinopathy after genral anesthesia for the treatment of ruptured intracranial aneurysm. OBSERVATION: A forty year-old man presented, after a general anesthesia for treatment of a ruptured intracranial aneurysm, with a severe decrease of the visual acuity in the left eye. Ophthalmic examination, performed one month after surgery showed a retrohyaloid macular hemorhage. After failure of laser Nd-YAG hyaloidotomy, vitrectomy allowed drainage of the hematoma with good visual outcome. CONCLUSION: Valsalva retinopathy is a rare complication that can occur after genral anesthesia. Vitrectomy may be needed if Nd-Yag laser hyaloidotomy fails.

Unilateral infiltration of the optic nerve revealing relapse of an acute lymphoblastic leukemia.

INTRODUCTION: Ocular infiltration of leukemia can involve orbit, uveal tract, retina and optic nerve. It may result from direct ocular infiltration by leukemic cells or indirect ocular involvement resulting from secondary hematologic changes, opportunistic infections and complications of various modalities of therapy. We report a case of unilateral infiltration of the optic nerve revealing a relapse of acute lymphoblastic leukemia. CASE REPORT: forty eight years-old woman in a remission of acute B lymphoblastic leukemia presented with headaches and blurred vision in the left eye. Ophthalmic examination showed a visual acuity reduced to 20/200 in the left eye, and a voluminous disc edema with papillary mass surrounded by retinal hemorrhages, exudates and important serous retinal detachment. CT scan showed a thickened left optic nerve and excluded true papillary edema due to intracranial hypertension secondary to central nervous system involvement. Myelogram and lumbar punction demonstrated blast infiltration and confirmed ocular relapse of the leukemia. CONCLUSION: The incidence of ocular involvement lymphoblastic acute leukemias decreased since the introduction of a systematic prophylactic treatment of central nervous system. Periodic ophthalmic examination is necessary to allow early diagnosis and treatment.

Association of carotido-cavernous fistula and controlateral optic neuropathy secondary to cranial trauma.

PURPOSE: to report a case of a woman who had a severe cranial trauma complicated by two ophalmologic potentially cecitating complications: right carotido-cavernous fistula and left traumatic optic neuropathy. OBSERVATION: A 56 years-old woman, without any medical history, referred, one month after fall from a height of 3 meters, for right exophthalmos. Ophthalmic examination of the right eye completed by retinal angiography suspected carotid-cavernous fistula which was confirmed by angio-MRI. In the left eye, the visual acuity was decreased to no light perception and fundus examination showed optic nerve head palor secondary to traumatic optic neuropathy. Arterial embolization was performed and allowed closing of the fistula. CONCLUSION: Optic neuropathy and carotido-cavernous fistula are two severe complications that can occur simultaneously in the same patient. The prognosis of the optic neuropathy may be compromised, and the treatment of carotido-cavernous fistula benefited from progress in interventional neuro-radiology.

Ophthalmic artery occlusion with total ophtalmoplegia and anisocoria revealing cavernous sinus thrombosis.

AIM: To describe a case of ophthalmic artery occlusion associated with anisocoria and revealing a cavernous sinus thrombosis due to sinusitis. OBSERVATION:   A 48-year-old man with a history of diabetes presented acutely with loss of vision and proptosis in the left eye. Ophthalmologic examination concluded in a left ophthalmic artery occlusion with anisocoria and total ophthalmoplgia. Cardiac assessment was normal. Magnetic resonance imaging (MRI) revealed left ophthalmic artery and internal carotid occlusions, left cavernous and transverse sinus thrombosis and sphenoid sinusitis. The patient underwent extensive haematological and medical assessment to search for embolic sources and disease causing thrombophilia. The patient recovered from the thrombosis episode, but sustained permanent blindness. CONCLUSION: Ophthalmic manifestations may be the only signs revealing cavernous sinus thrombosis which must be usually suspected. Visual prognostic was very poor.

Granulomatous uveitis and reactive arthritis as manifestations of post-streptococcal syndrome.

To report a case of bilateral granulomatous post-streptococcal syndrome uveitis in association with reactive arthritis as manifestation of post-streptococcal syndrome. To our knowledge, this could represent the first reported case in the literature. A 9-year-old girl, with no past ocular history, presented with a 5-day history of bilateral blurred vision, red eyes, photophobia and walking difficulties because of a right ankle pain. Ophthalmic examination disclosed a visual acuity limited to hand motion, mutton-fat keratic precipitates, anterior chamber cells and posterior synechiae in both eyes. Ocular pressure was normal. Physical examination showed a fever (38 °C), inflammatory ankle arthritis and scarlet fever (streptococcal lesion). Anti-streptococcal lysine O titer was 419 µ/ml. The patient was treated with topical steroids, cycloplegics, high-dose oral steroids and preventive course of penicillin with total improvement and no recurrence. Post-streptococcal syndrome should be considered in the etiology of acute bilateral granulomatous uveitis in children, and anti-streptococcal lysine O titer should be considered in serodiagnostic testing.

Herpes zoster ophthalmicus associated with abducens palsy.

The extraocular muscle palsies associated with herpes zoster ophthalmicus (HZO) are transient, self-limiting conditions, usually seen in elderly patients. There are different treatment recommendations for paralytic complications, but prognosis has generally reported to be favorable. A 75-year-old male patient presented with diplopia. Clinical history revealed left facial vesicular eruptions and pain treated by oral aciclovir 1 week following symptom onset. On examination, we observed cicatricial lesions with crusts involving left hemiface, a limitation in abduction of the left eye, and a superficial punctuate keratitis (SPK) with decreased visual acuity (4/10). Examination of the right eye was unremarkable. Hess screen test confirmed left six nerve palsy.

[Epidemiologic study of hyperopia in schoolchildren in Tunisia]. / Profit épidémiologique de l'hypermétropie en milieu scolaire primaire en Tunise: à propos de 6192 enfants.

AIM: To study the epidemiological profile and the degree of severity of hyperopia in Tunisia primary school and to assess its effect on school performance. METHODS: A cross-sectional, descriptive survey was conducted among 6-14 aged Tunisian children attending primary urban and rural schools. A total of 6192 children were selected using stratified random cluster sampling. Cycloplegic refractive error was measured among all children with uncorrected visual acuity less than 9/10 or signs of astheniopia. Hyperopia was defined as spherical equivalent (SE) 2.0 diopters (D). We have also searched a possible relation between degree of severity of hyperopia and school performance. RESULTS: The prevalence of hyperopia was 2.61%. The spherical equivalent mean was + 3.73 ± 0.94 D. The mean age was 9.67 ± 0.44 years. This prevalence was 2.77% in boys and 2.47% in girls. 3.13% of students were living in urban areas and 1.42% in rural areas. The hyperopia rate decreased significantly with age (p = 0.021), but it was not significantly related to gender (p=0.54). The difference in the prevalence of hyperopia between urban and rural areas was not statistically significant (p = 0.067). There was no significant association between the degree of severity of hyperopia and school performance (p=0.41). CONCLUSION: In our study, the prevalence of hyperopia among schoolage children in Tunisia was 2.61%.The identification of this refractive error and its correction as soon as possible would ensure these children better visual comfort and a better education.

Choroidal thickness measurement in highly myopic eyes using SD-OCT.

BACKGROUND AND OBJECTIVE: To measure macular choroidal thickness (CT) using spectral-domain optical coherence tomography (OCT) and to investigate the correlation between CT and age, degree of myopia, and history of macular choroidal neovascularization (CNV). PATIENTS AND METHODS: A cross-sectional study included 187 highly myopic eyes of 187 patients examined between January and December 2010. The choroid was imaged with spectral-domain OCT by changing the reference position from the vitreous to the choroid. CT was measured from the outer border of the hyperreflective line corresponding to the retinal pigment epithelium to the inner scleral border. RESULTS: The mean age was 47.21 ± 14.24 years, the mean spherical equivalent refractive error was -13.66 ± 5.77, and the mean subfoveal CT was 100.71 ± 59.98 µm. CT was correlated negatively with age (P < 10(-3)) and refractive error (P < 10(-3)). Forty-two eyes had a history of CNV, the mean CT was 55.45 ± 24.46 µm, and this was significantly thinner than in eyes without CNV (P < 10(-3)). CONCLUSION: In highly myopic eyes, the choroid is thin and undergoes further attenuation with age and increasing myopia. In addition, these findings suggest that the choroid may play a role in the pathogenesis of CNV.

Bevacizumab injection in patients with age-related macular degeneration associated with poor initial visual acuity.

Purpose. To evaluate functional and anatomic effects of intravitreal bevacizumab in patients with neovascular AMD and initial low visual acuity. Methods. Retrospective case series of 38 eyes with neovascular AMD and initial visual acuity of 20/200 or less, treated with intravitreal bevacizumab injection. Results. Mean followup was 14.1 months ± 7.1 (range: 5 to 24 months). Mean logMAR vision at baseline was 1.38 logMAR ± 0.33, at 6 months was 1.14 logMAR ± 0.37 (P = 0.001) and at 12 months was 1.22 logMar ± 0.33 (P = 0.004). Mean baseline central retinal thickness was 431 µm ± 159.7 at 6 months was 293.43 µm ± 122.79 (P = 10(-4)) and at 12 months was 293.1 µm ± 130 (P = 0.004). Visual acuity improved in both patients with or without prior PDT treatment. Conclusions. Intravitreal bevacizumab injection may increase the chance of visual acuity gain in neovascular AMD even in cases with initial low visual acuity.

Intravitreal bevacizumab versus photodynamic therapy for myopic choroidal neovascularization in a North-African population.

PURPOSE: To compare the 1-year functional and anatomical outcomes of intravitreal bevacizumab (IVB) and photodynamic therapy (PDT) in patients with myopic choroidal neovascularization (CNV). METHODS: Review of retrospectively collected data of 80 eyes in 80 patients with myopic CNV treated with standard PDT (n = 40) or IVB (1.25 mg/ 0.05 ml) (n = 40). Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) measured with optical coherence tomography (OCT) were compared between the two groups at baseline, 3, 6 and 12 months. RESULTS: In the IVB group, mean BCVA was +0.9 ± 0.85 logMAR at baseline. Mean BCVA was significantly better at 3 and 6 months than baseline (p = .0095 and p = .008, respectively) but not at 12 months (p = .065). In the PDT group, mean BCVA was +0.88 ± 0.45 logMAR at baseline, and improved to +0.85 ± 0.62 logMAR at 3 months and to +0.86 ± 0.44 logMAR at 6 months, which was not significantly different from baseline. Mean BCVA then decreased to +0.9 ± 0.54 logMAR at 12 months (p = .85). Mean logMAR VA was significantly better in the IVB group than in the PDT group after 3 months (p = .0043), 6 months (p = .0001) and 12 months (p = .0168). Mean CRT was significantly lower in IVB group than in PDT group at 3, 6 and 12 months (p = .008, p = .038, p = .040, respectively). Chorioretinal atrophy developed in six eyes (15%) treated with IVB and in 24 eyes (60%) treated with PDT at 12 months (p = 3.2 × 10(-5)). CONCLUSIONS: Over a 12-month period, intravitreal bevacizumab seems to be superior to photodynamic therapy in controlling myopic CNV in a North-African population.